2.0 Analysis 2.1 Introduction There were several areas worthy of examination in this occurrence, including the crew's reaction to the situation, the evacuation of the passengers, the lack of cockpit indications, the performance of the anti-skid and flight recorder systems, the nature of the CCOC failure, and the maintenance organization's response to the airworthiness directive. 2.2 Crew Performance and Evacuation There was no evidence that fatigue or other physiological factors adversely affected the crew's performance at the time of the occurrence. During the take-off roll, the pilots heard several bangs, but they saw no cockpit indications from which they could determine the nature of the malfunction. They interpreted these indications as ruptured tires. The captain decided to abort the take-off and executed the procedures in accordance with the airline's operations manual. When advised by ATC and ERS of smoke coming from the left engine, the captain carried out aircraft damage and evacuation procedures. It took several minutes to complete the evacuation. Two factors may have contributed to delaying the evacuation of all passengers. After the captain ordered the evacuation and the evacuation had commenced using the escape slide, he was advised that the threat of a fire was no longer present. He ordered that the remainder of the evacuation be completed by the airstairs. This change in the evacuation process, which required the deployment of the airstairs, undoubtedly resulted in a delay of a few minutes. The process may also have been prolonged by some passengers' attempts to take their carry-on baggage with them. 2.3 Emergency Escape Slide Standards and Performance The databases examined contain no consistent evidence that the existing standards for escape slides are inadequate to ensure the stability of slides in strong wind conditions. The emergency evacuation slide in this occurrence was forced up and against the side of the aircraft by the strong winds. One of the ERS personnel was able to stabilize the slide from his position on the ground, and the slide was effective in evacuating at least three of the aircraft's occupants. There is no evidence to indicate that the remaining occupants could not similarly have used the slide. Therefore, it is concluded that the slide met the FAR 25 airworthiness standards and that, in this instance, these standards were adequate. 2.4 Passenger Handling After Evacuation Following the evacuation, passengers waited up to 30 minutes for transportation from the runway to shelter. A number of passengers did not have adequate outerwear to protect them from the cold. Passengers were exposed to windchill effects equivalent to minus 16 degrees Celsius, and many reported discomfort despite the efforts of the flight attendants and the ERS personnel. Exposure to such conditions after an evacuation, for even 30 minutes, can have serious effects on both injured and uninjured persons. 2.5 Lack of Cockpit Indications Although the left engine EPR and rpm likely decayed rapidly after the CCOC rupture, the pilots observed no immediate cockpit indication of the engine failure. During the aircraft's deceleration, it is likely that some engineinstruments would have displayed evidence of the engine malfunction. This evidence may not have been noticed by the pilots, whose attention was focused on their primary task of stopping the aircraft on the runway.